Technical refinements in percutaneous nephroureterolithotomy

Percutaneous nephrostolithotomy and ureterolithotomy is now widely accepted as the preferred method of managing symptomatic upper urinary tract calculi. The success of these procedures depends on an optimally oriented, percutaneously established nephrocutaneous track. These nephrostomies are often technically difficult if the collecting system is unobstructed or if calculi interfere with percutaneous manipulations. Several technical refinements have been developed that have aided in the performance of over 200 such nephrostomies as well as percutaneous ureterolithotomy. These include the use of externally applied abdominal compression to distend the collecting system after intravenous administration of contrast material for renal puncture, distend the ureter beyond an obstructing ureteral calculus to aid in percutaneous extraction, and relocate ptotic kidneys back into the renal fossa to optimize renal access; targeting on an opaque caliceal calculus for nephrostomy puncture; use of a saline flush to confirm proper nephrostomy needle placement; and an accelerated method of track dilatation with semirigid fascial dilators. The value of air as contrast for postprocedural nephrostography is also discussed.